Week 3 - B - Management of violence and aggression - Mental Health Act Scotland 2003, Rapid Tranquilisation policy

Question 1

What is the definition of violence?

Answer 1

Violence is defined as the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation

Question 2

Is crime actually increasing or decreasing in recent years?

Answer 2

Crime is actually been seen to be decreasing in recent years contrary to what the media may have the public believe

Question 3

Does having a mental health disorder predispose you to violence?

Answer 3

Having a mental health disorder alone does not necessarily predispose somebody to a history of violence

Having a mental disorder with a history of violence or substance misuse greatly increases the predisposition to violence

Question 4

There are different ways to deal with aggressive behaviour but you should be trained to deal with aggressive type behaviour What are the different ways in which you may be able to manage aggressive behaviour?

Answer 4

Predict it - body language of patient - predicting it is the best way to avoid the aggressive behaviour because then you can prevent it

Prevent it - de-escalation, talk to the patient

Intervention to stop it - restraint, seclusion, rapid tranquilisation

Question 5

What prophylactic techniques can help to manage aggressive behaviour?

Answer 5

Think about the room layout, always stand closer to the door than the patient

Make sure to have the patient observed by the nurses try to have in a side room if worried about being aggressive as a stimulating environment may cause further confusion

Question 6

What are the three basic factors for detaining somebody?

Answer 6

This would be

They appear to have a mental disorder

They cannot make their own decisions

An they are a risk of safety to themselves or others

Question 7

There is an important need to understand which reasons you can detain somebody for under the mental health act and which you cannot When is a person not mentally disordered? (which disorders mean you cannot detain someone)

Answer 7

If the patient has alcohol or substance obuse

Behaviour that is likely to cause harassment, alarm or distress to another

Sexual orientation, devancy, transsexualism etc

Question 8

If someone doesn’t have a mental disorder they cant be detained, regardless of their actions What does somebody having a mental disorder actually cover?

Answer 8

Any mental illness, Learning difficulties Personality disorders

Question 9

What are the different components of the mental health (Care and treatment) act (scotland) that we need to know about?

Answer 9

Mental house office must also allow these after they have been put in

* Emergency detention

* Short term detention

* Compulsory treatment order

Nurses holding power

Advance statement

Question 10

Lets talk about emergency detention, short term detention and compulsory treatment order Who can use an emergency detention order? How long does it detain the patient for? What rights does the atient have under this order? What section of the mental health act scotland is this? Who must review the patient ASAP?

Answer 10

* Any registered medical practitioner can use the emergency detention order - that is FY2 and above

* It detains the patient for 72 hours but does not allow for treatment but merely assessment

* The patient cannot appeal this detention

* Emergency detention comes under section 36 of the mental health act Scotland

Usually there is consent from a MHO but you don’t need it.

It must be reviewed by an AMP as soon as possible.

Question 11

What are the criteria for detaining somebody under an emergency detention?

Answer 11

1. Likely to have a mental disorder
2. Patients ability to make decision about medical treatment for mental disorder are significantly impaired
3. Detention in hospital is urgent for treatment
4. Risk to health, safety or welfare of self and safety of other
5. Applying for a short term detention would involve unecessary delay

Question 12

Who can use a short term detention and compulsory treatment order

Answer 12

This would be an approved medical practitioner - usually somebody who as at least 4 years training in psychiatry (usually registrar and above) or is a member of the royal college of psychiatry

Question 13

Who can use short term detention order How long does it detain the patient for? What rights does the atient have under this order? What section of the mental health act scotland is this?

Answer 13

Can be used by an approved medical practitioner

Lasts for up to 28 days

Patient has the right to appeal this but this order is used as the patient can be treated This is section 44 of the MHA scotland 2003 To put this order through it requires MHO consent

Question 14

What is the criteria for using a short term detention order?

Answer 14

1. Patient is likely to have a mental disorder 2. There is significant impaired decision making regarding treatment due to the mental disorder 3. Detention in hospital is necessary for the assessment of the treatment 4. There a risk to health, safety or welfare of self or safety of others 5. The patient cannot be treated voluntarily

Question 15

Usually abut two weeks into the short term detention, have to make a decision about whether you are going to go for what detention?

Answer 15

Usually about two weeks into the STD, have to decide whether patient requires more treatment and if they are likely to refuse the treatment they need, then compulsory treatment order

Question 16

Who can apply for the compulsory treatment order ? How long does it detain the patient for? What rights does the atient have under this order? What section of the mental health act scotland is this?

Answer 16

The CTO needs to be applied to the mental health tribunal with two accompanying reports - one from a ST4 and up (in psychiatrist) treating the patient and another usually from the GP

The compulsory treatment order lasts up to 6 months

* The patient has the right to appeal as they do in the STD - to the tribunal of mental health and welfare committee * MHO consent needed This is section 63 of the mental health act

Question 17

What order can the police put in place? What are the conditions?

Answer 17

Police have a specific provision called he patient safety order if they find somebody, they can use this order to take them to a safe place and they are obliged to stay with the person whilst they are assessed – this can only happen in a public place (police are not allowed to go into a persons own home and detain them under this order)

Safe place can mean ie psychiatric hospital or A&E

Question 18

What can nurses do if someone needs detaining and there is no doctor present?

Answer 18

The nurses holding power allows a nurse to withhold a patient for up to 2 hours until a doctor is ready to assess the patient

Question 19

When a patient presents violently It is important to first and foremost try and use non drug approaches Elicit the use of distractions, seclusion and even try and simply talk to he patient Before adminsitering a drug what should you do?

Answer 19

Before administering a drug, be aware of the patients past medical history to check for any drug contraindictions and then first of all try oral therapy

Question 20

What drug is attempted for oral therapy in a patient who is violent?

Answer 20

This would be lorazepam

Question 21

Rapid tranquillisation is the use of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral medication is not possible or appropriate and urgent sedation with medication is needed. What drug is attempted to be given IM mainly?

Answer 21

IM lorazepam 1-2mg is what is usually given to sedate the patient, can try in combo with haloperidol sometimes

Question 22

After giving a patient the IM lorazepam, what should be monitored? What happens if there is no response to the lorzepam first injection?

Answer 22

After giving IM lorzepam, monitor resp rate, pulse BP every 5-10 minutes for one hour

If no respponse to first injection after thirty minutes, give another dose of lorazepam injection

If no response, seek senior help

Question 23

The management of a delirious patient is slightly different to the management of a patient who is being treated for violence/aggression What pharamcology can be given to the delirious patient 1st? What happens if the delirious patient has lewy body dementia or parkinsons? What happens if they were delirious due to alcohol or benzo withdrawal?

Answer 23

Delirious patient normally 1st line is normally 0.25 mg haloperidol

If the patient has DLB or DPD - then give lorazepam usually (quetiapine can be given instead (an atypical so not as much effect on D2 receptor antagonism))

If the delirium was due to alcholol or benzo withdrawal - then give a benzodiazpeine

Question 24

What are causes of potential psychiatric issues that you cannot detain somebody for?

Answer 24

Intoxicated with, addicted to or withdrawing from alcohol or drugs - so substance misuse

Cannot detain somebody for disorders or sexual preference

Cannot detain somebody if there is no treatment available for their condition